Kristiansen et al. BMC Health Services Research (2015) 15:225 DOI 10.1186/s12913-015-0901-5

RESEARCH ARTICLE Open Access Migrants’ perceptions of aging in and attitudes towards remigration: findings from a qualitative study Maria Kristiansen1*, Linnea Lue Kessing1, Marie Norredam1,2 and Allan Krasnik1,3

Abstract Background: The increasing number of elderly migrants in Europe poses challenges for the organisation of healthcare and social services if these migrants do not remigrate to their countries of birth at old age. More insight into perceptions of aging among migrant women is needed to inform service delivery for culturally and linguistic diverse populations, yet few studies have explored this field. The aim of this study is to explore perceptions of aging among middle-aged migrant women, with emphasis on identifying factors shaping their decisions on whether to remigrate or stay in Denmark during old age. Methods: The study is based on 14 semi-structured interviews including a total of 29 migrant women residing in , Denmark. The women were born in Somalia, Turkey, India, Iran, Pakistan, or Middle Eastern countries. The majority of participants were middle-aged and had one or more chronic illnesses. The analysis was inspired by phenomenological methods and guided by theory on access to services, social relations, and belonging. Results: The results showed that the existence of chronic conditions requiring frequent use of medical care and the availability of high-quality healthcare in Denmark were important factors for the decision to spend one’s old age in Denmark rather than to remigrate to one’s country of origin. Similarly, availability of social services providing financial and tangible support for the elderly was perceived to be important during old age. For these middle-aged women, social ties to children and grandchildren in Denmark and feelings of belonging further nourished a wish to stay in Denmark rather than remigrating. Conclusions: Since the study suggests that elderly migrants will be utilising healthcare and social services in Denmark rather than returning to their countries of birth, these services should prepare for increased cultural and linguistic diversity among users. This could entail provision of translators, specific outreach programmes, and culturally adapted services to meet elderly from diverse linguistic, religious, and cultural backgrounds. Keywords: Migrants, Europe, Aging, Healthcare services, Social services, Adaption, Return Migration

Background old age, particularly in Europe [3, 4]. Elderly migrants may The increasing number of elderly individuals worldwide have different healthcare needs, for example due to diffe- has resulted in growing demand for long-term care, with rent morbidity patterns and language barriers [5]. Further- implications for the organisation and financing of more, their expectations of family support and social care healthcare and social services [1, 2]. Along with these services for the elderly may also differ from those of the demographic changes, migration flows have led to an in- ethnic majority [6, 7]. The growing population of elderly crease in the number of migrant populations approaching migrants in Europe comprises both refugees and people who have come to Europe through voluntary migration. * Correspondence: [email protected] Socioeconomic and cultural background, number of years 1Center for Healthy Aging, and Research Centre for Migration, Ethnicity, and since immigration, possibility for returning to country of Health, Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Øster Farimagsgade 5A, 1014 Copenhagen K, birth, morbidity patterns, and language skills are but a few Denmark of the many factors that are likely to shape experiences of Full list of author information is available at the end of the article

© 2015 Kristiansen et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kristiansen et al. BMC Health Services Research (2015) 15:225 Page 2 of 12

aging and need for health and social care among elderly healthcare according to need. Access to general practi- migrants in Europe [4–9]. The rapid increase in the pro- tioners and is free of charge, though many ser- portion of elderly migrants has heightened the need to vices for chronically ill elderly people (such as dental clarify questions of migrants’ perceptions of aging and services, drugs, physiotherapists, and glasses) require their potential end-of-life wish to return to their countries out-of-pocket payments [13]. About 14 % of the expen- of birth. ditures are out-of-pocket payments. Migrants who hold Anwar [8] proposed ‘the myth of return’ to explain residence permits are covered by the Danish National how migrants dream of returning to their countries of in the same way as is the rest of the birth but in reality often end up staying in the country Danish population [14]. of immigration. Based on research on first-generation Social services for the elderly population in Denmark Pakistani immigrants in Britain, Anwar [8] explores how encompass a range of services delivered at the municipal plans for returning to Pakistan were maintained over level in addition to state pensions. Home care is avail- time. Obligations to relatives in Pakistan and economic able upon referral and involves support in maintaining and social ties, consisting of flows of remittances, invest- activities of daily life, including cleaning, personal ment abroad, and visits, nourished their wish to return hygiene, and intake of medication with the aim of enab- to Pakistan even when their stay in Britain became more ling the elderly to remain in the community for as long permanent following the arrival of the closest relatives. as possible. For people with significant care needs, Gardner [9] also finds that elderly migrants glorify their homes for the elderly are available. Non-governmental countries of birth as the places they truly belong even organisations facilitate access to a range of psychosocial though this relationship changes with time, and very few services and educational activities such as computer realise the dream of returning. classes, travel, and lectures for the elderly although, to During an economic boom in the 1960s and 1970s, our knowledge, few activities are in place for elderly mi- the Danish state invited workers primarily from Turkey, grants. A migrant is entitled to receive state pensions if Pakistan, Morocco, and the former Yugoslavia to Denmark. his or her country of birth has a treaty agreement with In 1973, measures were put in place to limit labour immi- Denmark. This amount increases with the duration of gration, and in the 1980s and 1990s, labour immigration one’s stay in Denmark, and refugees are entitled to flows were superseded by incoming refugees from Iran, the maximum state pension [15]. Most Danish citi- Afghanistan, the former Yugoslavia, Somalia, and Iraq as zens supplement their state pension with private pen- well as migrants arriving through family reunification. sions whereas the income among elderly migrants is Through family reunification programmes, migrants grad- often lower due to their shorter inclusion in the ually settled down and became visible in all parts of the Danish labour force. Danish system. Immigration patterns thus changed from In Denmark, neither healthcare nor social services temporary to ‘temporary permanent’–a concept indicat- have been systematically adapted to the needs of the ing a dream of eventually returning to the country of rising elderly migrant population. Such needs include birth [10]. In recent years, new groups of migrants provision of translators, specific outreach programmes, have arrived, mostly from Eastern Europe. Migrants and culturally adapted services to meet needs among an and their descendants now constitute 10.5 % of the elderly population representing diverse linguistic, reli- Danish population [11], with 15,940 migrants from gious, and cultural backgrounds. However, to ensure non-Western countries aged 65 years or over. This appropriate services for elderly migrants, we need number of elderly migrants is set to increase fourfold more insight into perceptions of aging among these in the next 20 years [12]. In this study, we focus on groups [1, 6, 7]. The overall aim of this study was the group of aging migrants who arrived predomi- thus to explore middle-aged migrant women’s percep- nantly from countries with Muslim majorities. These tions of aging in Denmark and more specifically the groups tend to be economically disadvantaged in factors shaping their perceptions of whether to remi- Denmark and have arrived to Denmark from coun- grate or stay in Denmark during old age. tries with poor educational systems as well as poor health and social services. Methods Healthcare services are essential for the increasing The paper is based on a qualitative study exploring elderly migrant population in light of rising morbidity screening behaviours among middle-aged migrant women and functional decline. In Denmark, over 80 % of health- who have migrated from non-Western societies with care expenditure is financed by the state – mainly Islam as the predominant religion [16]. The study focuses through taxation at the state and municipal level – and on participation in mammography screening as an ex- is mostly free of charge for all residents. This system ample of health behaviour of significant importance due aims to provide residents with easy and equal access to to lower participation rates in mammography screening Kristiansen et al. BMC Health Services Research (2015) 15:225 Page 3 of 12

among migrant women compared to native-born women Table 1 Demographic information [17]. A broad approach was taken in order to situate Name Agea Duration of residence Type of health behaviours within the context of migrant women’s in Denmarkb interview everyday lives in Denmark, including their access to Participant 1 2 3 Individual healthcare and social services and their overall quality of Participant 2 2 4 Individual life. The study thus aims to acknowledge the interrelation- Participant 3 3 4 Individual ship between health and social factors as well as the im- Participant 4 3 3 Individual portance of taking into account women’ssocialcontexts locally in the country of immigration and extending Participant 5 3 Missing data Individual beyond national borders to their country of birth. One of Participant 6 2 4 Individual the issues of concern for the middle-aged women enrolled Participant 7 2 2 Individual in the study appears to be adjusting to the prospect of Participant 8 2 2 Individual aging and in particular deciding whether to stay in Participant 9 2 4 Group Denmark during the last parts of their lives or returning Participant 10 3 1 Group to their countries of origin. The data underlying this paper thus focuses on the factors related to perceptions of aging Participant 11 3 4 Group that weigh particularly on this decision-making process Participant 12 1 2 Group from the middle-aged migrant women’s perspectives. Participant 13 2 Missing data Group Since the paper builds upon data collected for a study Participant 14 4 4 Group exploring gender-specific health behaviour (mammog- Participant 15 2 2 Group raphy screening), we are unable to include the perspec- Participant 16 2 2 Group tives of elderly migrant men. Inclusion criteria for participation in the study were Participant 17 4 1 Group based on age (50–69 years) in order to capture women Participant 18 2 3 Group in the target age groups for the Danish mammography Participant 19 3 4 Group screening programme; country of birth (only including Participant 20 Missing data 4 Group women from non-Western countries known to have low Participant 21 1 3 Group utilisation of this programme); and residence (Copenhagen) Participant 22 2 3 Group to ensure inclusion of women with few access barriers in terms of geographical distance to screening sites. Participant 23 2 4 Group We recruited women directly and in some cases used Participant 24 2 2 Group gatekeepers from communities with high numbers of Participant 25 1 2 Group migrants, a mosque, and drop-in centres for pensioners Participant 26 3 2 Group or migrants. In addition, snowball sampling was used. By Participant 27 3 2 Group recruiting through existing social networks among the Participant 28 3 3 Group target group, we were able to include women who might otherwise have been less inclined to accept research par- Participant 29 3 3 Group a ticipation. The final sample of interviewees consisted of Age in years: 1 = [40–49], 2 = [50–59], 3 = [60–69], 4 = [70≤] bDuration of stay in years: 1 = [0–9], 2 = [10–19], 3 = [20–29], 4 = [30≤] 29 women, comprised of women born in Somalia (6), Turkey (5), Pakistan (4), India (2), Iran (1), and Middle women were less vocal during interviews, and the per- Eastern counties with Arabic as the majority language spectives of the three younger women did not surface in (11). Interviewees differed in terms of duration of resi- discussions related to aging. Statements from these five dence in Denmark, with some women having arrived interviewees therefore do not feature in this paper. In rather recently and others being long-term residents general, interviewees had obtained a rather low level of (Table 1). Among interviewees, five women were refu- education (the vast majority had primary school only), gees while the rest had migrated to Denmark through and few of them had previous or current employment. family reunification. Due to recruitment in existing Although chronic illness was not part of the inclusion social networks and community centres, a few women criteria, most interviewees suffered from one or more wishing to attend group interviews were slightly youn- chronic condition, such as hypertension, diabetes, high ger/older than the age-range set out in the inclusion blood pressure, heart problems, and arthritis. Most criteria. This was the case for five women (ages 47, 48, women were Muslims though religious identity was not 49, 78, and 90). We decided to include these women in explicitly discussed during interviews. interviews for ethical reasons and to ensure an appropri- Women were informed about the aim of the study as ate atmosphere for the interviews. The two elderly well as research ethics, including confidentiality, storage Kristiansen et al. BMC Health Services Research (2015) 15:225 Page 4 of 12

and use of data, and the right to withdraw at any time engagement with women, for instance during gatherings during the study. This was explained both orally and in at drop-in centres for pensioners and mosques, was thus writing in Danish, with interpretation provided as neces- both a gateway to recruitment and a method of collecting sary by either professional interpreters or bi-lingual data on social networks, quality of life, and feelings of staff/volunteers at the mosque, drop-in centres, or com- belonging among these middle-aged migrant women for munity groups where recruitment took place. Oral in- use as contextual information and in the preparation of formed consent was given by all participants before interview questions. interviews were conducted. According to official Danish The first and the second authors of the present paper research guidelines, no approval from ethical commit- conducted eight individual interviews and six focus tees is needed for interview studies. The study was group interviews in the period from September to approved by the Danish Data Protection Agency. November 2011. Challenges in ensuring participation in Data was collected through a combination of indivi- group interviews forced us to compromise on the num- dual semi-structured interviews, focus groups, and infor- ber of participants involved in each focus group. This mal observation conducted during recruitment and prior issue arose mainly because some women did not attend to/following interviews. Observations focused on struc- the scheduled interview session. We decided to conduct tures and functions of social networks among women; the interviews with the women who did attend the ses- exchanges of tangible and emotional support in these sion for ethical reasons although this compromised our networks; and visible community factors shaping quality ability to achieve the dynamics that were the purpose of of life, including isolation, integration, and insecure choosing this interview type. In total, six group inter- neighbourhoods. The combination of two types of inter- views were conducted, each involving 2 to 7 participants. views was based on our intention of gaining insight into Each interview lasted 30 to 90 min. how perceptions of aging and factors influencing these The interview guide discussed mammography screen- experiences are constructed and negotiated within social ing as a part of the larger context of everyday life among relationships. Focus groups gave voice to important migrant women. This included questions concerning dilemmas, for instance regarding the pros and cons of perceptions of aging; quality of life and the meaning of remigration, while a more in-depth understanding of social relations; feelings of belonging to Denmark, coun- individual life stories was obtained through individual try of birth, and diaspora communities; experiences with interviews. Each type of interview entails a number of and perceptions of Danish healthcare and social services; ethical considerations. Focus groups turned out to be and use of healthcare and social services in their country very dynamic, with a high degree of discussion and par- of birth (Table 2). Literacy issues were evident among ticipation although group dynamics at times silenced interviewees, partly due to differences in language skills individual women, who did not seem fully comfortable and little formal education. To overcome language dif- voicing their opinions, partly due to the risk of breaches ferences, professional interpreters were used in a total of of confidentiality. Individual interviews were more in- seven interviews. The use of interpreters presented chal- timate and facilitated disclosure of private and sensitive lenges for interaction between interviewer and interviewees, information, e.g. in terms of isolation, illness experi- Table 2 Topics discussed during interviews ences, and tensions within family relationships. Focus • groups were composed based on language group and Migration history: motives for migrating, experiences during migration and perception of changes in health and social circumstances were facilitated by the researchers. One focus group con- following arrival in Denmark sisted of women with diverse native languages who met • Everyday life in Denmark: social relations to relatives, friends and the regularly at a community centre and spoke Danish. Each wider society, integration and feelings of belonging, roles and interviewee (expect one) only participated in one type of responsibilities within families, quality of life, aging expectations, interview. remigration Recruitment was relatively lengthy since emphasis was • Perceptions of health: health status, importance attached to health promotion and early detection, utilization and perceived quality of placed on involving women who are otherwise under- Danish healthcare services (general practitioner, hospitals and represented in health behaviour studies in many European screening programmes) and social services, access barriers (language, countries due to a combination of lack of familiarity with knowledge, motivation, social network involvement, geographical distance), perceived risk of diseases research engagement and cultural, socioeconomic, and • linguistic challenges. Ensuring that potential interviewees Perceptions of cancer in general and breast cancer in particular: causes of cancer, severity, perceived vulnerability, family history of cancer, were well informed and felt comfortable participating in experiences with cancer in country of birth and in Denmark the study was important for creating a trustful and • Mammography screening: awareness, knowledge of content of comfortable interview setting, and it enhanced our insight invitation and procedure, experiences with participation, barriers for into the life worlds of women in alignment with the phe- participation and facilitating factors, perceived pros and cons of the programme, suggestions for improvement nomenological starting point for our study. Informal Kristiansen et al. BMC Health Services Research (2015) 15:225 Page 5 of 12

particularly during group interviews [18]. However, all may have children and grandchildren born and raised in interpreters were trained and had insight into the purpose the country of immigration, feelings of belonging may be of the study, qualitative methodology, and research ethics, complex and intrinsically associated with social relations. which helped overcome some of the difficulties associated Analysis was independently conducted by two re- with use of interpreters in qualitative studies. At the end of searchers and later compared and discussed until each interview, a short questionnaire was handed out with agreement was achieved on identified emerging themes, questions about country of birth, number of years in their conceptualisation, and coding of meaning units. To Denmark, morbidity, and household status. Again, due to further enhance data analysis, findings were presented and literacy issues, most interviewees completed the question- discussed within the research group. Data analysis pro- naire orally, with researchers noting down their answers to ceeded through three steps: First, all transcripts were read questions. A few interviewees expressed specific support in their entirety in order to gain an impression of the text needs during the interviews (e.g. raised certain health ques- as a whole. This was followed by abstraction of major tions or asked for help with getting in contact with specific themes related to perceptions of aging and identification services), and we did our best to assist them. All inter- of meaning units associated with these themes across the viewees were acknowledged with a gift basket. Interviews interviews. Finally, the essence of the particular theme was were transcribed verbatim in Danish by one of the synthesised into a consistent statement across interviews, interviewers. The transcripts from interviews in which an thereby moving from the concrete to a more abstract level interpreter was involved were authenticated by a second in- of understanding. terpreter, who confirmed the correlation between the con- versation in the given native language and what was Results transcribed. This was followed by preliminary analysis of We identified the following factors shaping perceptions data conducted by two of the authors, who jointly deter- of where to live during old age: 1) importance of access mined the point in the fieldwork process when little new to healthcare services, 2) availability of social services, information was produced, after which data collection was and 3) social relationships and feelings of belonging. concluded. These themes will be described below.

Data analysis and theoretical framework Importance of access to healthcare services Data was analysed through multiple readings of the Co-morbidities and functional decline are increasingly material. The analytical approach was phenomeno- common with old age. Most of the women interviewed logical, with emphasis on gaining insight into the lived had one or more chronic conditions that affected their experiences of aging [19]. The attention to immediate daily lives and brought them into frequent contact with experiences and the meanings attached to them helped primary and secondary care. ensure a data-driven analysis process. Analysis was thus Ensuring continued access to quality healthcare ser- driven by themes emerging as important for experiences vices was articulated as important for women’s current of aging. Through initial readings of transcripts, themes health status, and they anticipated that this factor would related to access to healthcare services, availability of so- be even more important as they aged. Assessments of cial services, and psychosocial aspects related to social need for healthcare services were thus shaped by tem- relationships and feelings of belonging emerged. Theor- poral comparisons with women experiencing declining ies on access to services, social relations, and feelings of health at middle age and expecting further decline in up- belonging were thus used to inform the more detailed coming years. In addition, inter-country comparisons level of analysis. Access to healthcare and social services were common. Remigration was not desirable as it would was conceptualised as the actual right to use services entail risks of inappropriate or inaccessible healthcare. In and as satisfaction and trust in these services [20]. The discussions of differences between their current living concept of social fields provided a method of examining circumstances and those that would be available to them social relations as a set of interlocking networks of social if they chose to remigrate, interviewees explained how relations through which ideas, practices, and resources fragmented, low-quality healthcare systems requiring out- are exchanged, organised, and transformed both within of-pocket payments would make it difficult to ensure nation-states and through transnational ties [21]. Fee- proper treatments for their chronic health conditions. lings of belonging were conceptualised based on the per- They thus carefully considered pros and cons of various ceptions that global migration flows create new identity systems in the light of their morbidity. For some women, structures in which people feel attached to more than inter-country comparisons were based on more recent one nation-state and that identity, rather than being con- visits to their countries of origin, through which they had fined to one particular nation-state, may span across assessed the living conditions available to them should countries simultaneously [22]. For migrant women, who they choose to remigrate. This was primarily the case for Kristiansen et al. BMC Health Services Research (2015) 15:225 Page 6 of 12

those women who had arrived to Denmark through family Participant 22, an Iranian woman, described the neces- reunification coming from relatively ‘safe’ countries such sity of actively requesting referrals from her GP: “Some- as Turkey, Pakistan, Morocco, and India. These women thing I’ve learned from the beginning is that I don’tgo comprised the majority of our sample (17 out of 29 inter- [to the GP] and say: ‘Do you think I should go to the viewees). In contrast, refugee women from Palestine, Iraq, ?’ Instead, I say, ‘I’d like you to write that I have Iran, Jordan, and Somalia more often referred to media to go to the hospital’”. reports, experiences of relatives, or the state of services In discussions about reactions to symptoms, women available prior to their emigration, thereby bringing a tem- explained that they felt confident seeking consultation poral dimension into the comparisons. In a group discus- from their GP. Language barriers were rarely mentioned, sion, Participant three outlined the differences between and access to primary care in Denmark was perceived as healthcare services in Denmark and India: similar to that in their countries of birth, apart from the barrier caused by co-payment in their countries of birth. There are all those pros and cons on both sides Participant seven from Turkey said that she would en- [in relation to staying in Denmark or returning to gage in the same health-seeking behaviours in Denmark India]. Over there [in India], we can do the same as in her country of birth: “Here, in Denmark, I would, things as we can do if we fall ill here of course, talk to my own doctor, the same as in Turkey. [in Denmark]. We have to make an appointment, If I suspect [that something is wrong] in Turkey, then and that takes time, but it [the treatment] is free I’d see a doctor and talk about it.” Most women did not [here in Denmark]. Over there [in India], on the travel to seek treatment but only used healthcare in their same day, we would go, pay money, and we get country of birth if needed when visiting relatives. the answer [regarding diagnosis and appropriate Experiences with secondary care were mostly asso- treatment]. So, in our country, if we have money… ciated with inpatient care for chronic conditions and moneyisveryimportant(…). If I return, then I childbirth. The temporal aspect of comparisons was evi- need to have a lot of money. dent here, with women narrating how resources in the healthcare system had worsened in recent years, result- The husband of Participant three was ill, and she ing in poorer quality of care, longer waiting lists for suffered from chronic diseases. Availability of healthcare treatment, and shorter hospital recovery periods. Partici- services strongly shaped her considerations as to whether pant three explained: “It isn’t the same treatment any- she should remigrate to India. While she spoke about her more (…) Cost savings are happening everywhere now”. dream of returning to India, financial factors caused her Participant three also felt the constraints on referrals to to stay in Denmark in practice. specialist care: “Often, they [GPs] are good but still they Regular contacts with general practitioners (GPs) were won’t help or… I don’t know, it’s like they’re reluctant to common among all of the women. Most found their GPs provide us with referrals [to secondary care]”. to be easily accessible and had a trusting relationship The overall impression of access to and quality of pri- with him/her, as described by Participant four, who was mary and secondary care was, however, still positive born in Somalia: among the women.

Whenever I go [to the GP], she takes me seriously Importance of availability of social services because she’s been by doctor for almost three years The vast majority of interviewees were retired or re- now. So, she informs me about so many things that I ceived social benefits (social security or disability should consider [in terms of coping with disease]. benefits) and were thus dependent on social services for Because I have… she has to check me with regards to their income. In addition, due to their multiple chronic my liver condition. I have my heart [disease], I have conditions and functional decline, most of the women asthma… So, all these complications. I take medicine were in a position in which they needed or soon would for the asthma, blood pressure, and I mess up. need help from others in managing daily tasks such as Sometimes, I don’t know where I’m going. So, when I cleaning and shopping. Therefore, availability of social tell her that, she takes me seriously. She calls me services was viewed as an additional important factor for when my blood isn’t… if it’s very high. She sometimes deciding where to spend old age. calls me and tells me: “You have to come”. So, she Most interviewees had children, and in some instances takes me seriously, I’m lucky. also grandchildren, living in Denmark. They all agreed on the importance of living either with or near their Few women mentioned access problems or perceived children in order for their children to provide practical inadequate care from their GP, for instance in relation and/or emotional support as they grew older and to to referral to appropriate secondary care. However, ensure the maintenance of social roles within extended Kristiansen et al. BMC Health Services Research (2015) 15:225 Page 7 of 12

families. Some women discussed changes in family sociocultural context in Denmark, especially when dual values and contexts for family life across generations responsibilities for younger generations challenged care and between countries, noting how their children had provided within extended families. established their own families and needed to manage In addition, experiences were shaped by the realm of multiple responsibilities in relation to work and family. possibility that women perceived was within their reach. The women reflected on the strain on these young Whereas those women who came to Denmark as volun- families and articulated a wish to be able to continue tary migrants could reflect upon the desirability of remi- helping the younger generation in their everyday lives gration, refugee women with little or no opportunity of despite their transition into old age. Some women also returning to their countries of birth had little alternative feared that the stressful lives of the younger generation but to come to terms with aging in Denmark. The differ- would result in less care for them as they got older. In ent issues facing voluntary migrants as opposed to refu- their discussions about aging and quality of life, some gees is illustrated by the following quote articulated by women reflected on the positive aspects they associated Participant 13, a Palestinian refugee woman, during a with Danish homes for the elderly in particular, mainly group discussion of the pros and cons of social care in since they symbolised publicly funded services that could Denmark versus their countries of birth: “You’dpreferto supplement – or if need be – replace family-based die in your own country rather than dying in a foreign support for the elderly. Alternatives to homes for the country (…) And no matter where you live and how well elderly, and in particular availability of home care, did you’re feeling in another country, it’s always more pleasant not emerge during discussions. Women articulated that and better to return to and die in your own country”. social services in Denmark should be adapted to meet Participant 13 describes herself as a foreigner in the needs of elderly migrants, e.g. in terms of overcom- Denmark and feels a sense of belonging to her country ing language barriers and the loneliness that this may of birth. A dream of returning thus still existed, yet for lead to among migrants with limited Danish skills. In a many of the women who came to Denmark as refugees group interview, Participant three expressed this need from Palestine, Somalia, or Iran, it was impossible to for language-specific homes for the elderly: return due to security, legal, and financial issues. Partici- pant five, a woman from Somalia, explained how she I’ve been in England, where they have [homes for the cared for her paralysed ex-husband in Denmark, hoping elderly] available in their own language. Like Punjabi, he could repatriate to Somalia. She was in doubt as to it’s only for Punjabi people, only Punjabi, and only for whether she could return to Somalia herself since she had Indian people. My husband has been there. a child and grandchildren in England and family to sup- port financially in Somalia through her Danish pension: Cultural differences and notions of belonging were also perceived as challenges that should be considered in I’d like to help him [the ex-husband]. Take him to the provision of care for elderly migrants. Participant 22, Somalia when he gets permission to repatriate. who had migrated to Denmark from Iran, pointed out [Interviewer: But you wouldn’t like to stay there the need for homes for the elderly to be adapted specif- [in Somalia]?]. First, let’s see how he’s feeling. ically to migrant populations whilst acknowledging the If I think it’s okay, then I’ll do it [stay in Somalia]. difficulties such tailored services could entail: If it turns out to be fine, then I want to… If it’s possible that way. I think there should be at least one home for elderly for migrants per municipality (…) We understand Interviewees who were not refugees often attempted each other because I’ve seen this [experienced the to combine living in Denmark with longer stays in their same things as other migrants], and it helps a bit. I countries of birth, mostly through regular travel, but due know there’s a fear that such a home could turn into a to restrictions on stays abroad by people receiving social ghetto. benefits, this was often hard to accomplish. A woman from Turkey explained how she would prefer to stay six Although the women in general seemed to have a months in each country annually but was prevented positive view of Danish social services, some voiced from doing so due to such legislation. certain reservations about growing old in Denmark, Most women wished to stay in Denmark since this particularly in relation to becoming isolated in homes would enable their children and grandchildren to take for the elderly. Women thus articulated how cultural care of them and since this opened up the possibility of values and social norms surrounding appropriate care accessing support from Danish social services if needed. for and roles of the elderly perceived to be common in However, a few women, most of whom were refugees, their countries of birth had to be adjusted to the mentioned their desire to die in their countries of birth. Kristiansen et al. BMC Health Services Research (2015) 15:225 Page 8 of 12

Emphasis given to social relationships and feelings of 40 years, explained: “I feel more Danish in my behaviour belonging and thinking [the way I think] and such things, but The women’s social relationships in Denmark and a fee- Pakistan is still inside of me. But when we travel to ling of belonging had over time created a desire to stay in Pakistan for a month and up to a month and a half, then the country during old age. The geographical location of you get tired, then you would like to go home [to their husbands and children seemed particularly impor- Denmark]”. tant for their decisions to stay in Denmark. In a group Others, mostly refugees, who had spent much less interview, Participant 15, who was born in Iraq, spoke time in the Denmark, often said that they still felt about her possibilities of returning to Iraq: “Because we strongly connected to their countries of birth. Concur- have children here, my daughter here, and all family here, rently, the women described how they valued the dem- what should I do in Iraq? Only my mother [is in Iraq]. My ocracy and feeling of safety in Denmark, pointing out mother is an old lady, and my sister. But all family is here. that discussions on returning were an ongoing dilemma. Ican’tleave”. Inter-country comparisons were obvious as these women Temporality again surfaced in the women’s accounts. came from politically unstable countries with extreme They explained how, in the process of settling down in poverty, and Denmark had become a safe heaven. Return Denmark, they had gradually become embedded in migration was often not possible for these women due social relations, and relatives and friends in their coun- to economic difficulties and lack of security in their tries of birth were gradually accorded less importance countries of birth. Participant one, a Palestinian woman over time. who fled from Jordan, explained: The issue of returning during old age was an ongoing dilemma in the women’s lives. It was clearly a topic they For me, I’m happy to be here. Especially, as I told you, had discussed with each other before, with the result when I came to Denmark, we feel free. Here, we can that they actively spoke about the dilemmas during the talk… We can do what we want. I mean, especially, interviews. Few women appeared determined not to we were forbidden [in country of birth], afraid to talk return. As Participant 22, an Iranian woman, explained: about everything. (…) Now it’s too late to [return]. “I’ve fled [the country], and I’ll never return. So for me, I feel like, this country, I’ve got used to it. I came here that’s clear.” She had witnessed the killings of her father when I was nearly 30, 32, something like that. Now, and brother and had fled to Denmark alone and had since I’m nearly 60, so I’ve got used to it (…). then focused on creating a social network in Denmark. The majority of the women had also established social Participant one articulated how she no longer felt lives in Denmark, with important social relationships she belonged to one specific geographical location with other migrants living in the country. Social rela- and how she felt she could not identify with a spe- tionships with women living with similar dilemmas per- cific nationality: taining to feelings of belonging and pros and cons of returning to countries of birth were clearly important I’m half Syrian, half Jordanian, or half Syrian, half sources of support and understanding. These relation- Palestinian, and I feel with the ships also influenced their desire to stay in the country. The women who came to Denmark for family reunifi- Syrian that I’m Syrian, I feel with the Palestinian that cation and had their closest relatives in the country I’m Palestinian. But at the same time, I just like to be generally expressed a wish to stay in Denmark, but ques- Muslim. All nationalities, for me, I don’t like it, I tions of returning to their countries of birth during old don’t feel it. Of course, I have a tradition with foods age still seemed to be a point of discussion among them. and all that, but I love Muslims, I love them, really, I Feelings of belonging in Denmark, however, were natur- love them. Of all nationalities, whatever they are, I ally influenced by the amount of time spent in the coun- love them. try and their reasons for migrating. Expressions of identity phrased as “feeling Danish or partly Danish” Throughout their time in Denmark, the women had were common among the women with a longer duration settled down with families and friends and had come to of stay in Denmark. Most of these women had migrated an understanding that the immigration country was a to the country for family reunification and found it diffi- place of permanent residence rather than a temporary cult to imagine returning to their countries of birth, solution meeting the needs for security and prosperity partly due to having undergone significant changes that had been the causes of migration. Women thus themselves since emigration and partly due to changes articulated their desire to stay in Denmark during old that had occurred in their countries of birth. Participant agealthoughtheysimultaneouslyfeltattachedtoother 23 from Pakistan, who had lived in Denmark for almost geographical locations. Kristiansen et al. 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Discussion healthcare rights among [24, 25]. However, particularly Among this sample of middle-aged migrant women, at an age with increasing morbidity and functional de- most of whom suffered from chronic disease, percep- cline, such healthcare services may be preferable to tions of aging and attitudes towards remigration were those of low- or middle-income countries. shaped by the importance of easily accessible and high- As for social services, it seemed that interviewees held quality healthcare services as well as the availability of surprisingly positive views concerning homes for the social services perceived as being needed during old age. elderly, although it is difficult to judge from the inter- Social relationships and feelings of belonging in the views whether the women would actually use them or country of immigration further informed the decision preferred care provided within family networks. Most of not to remigrate, and the women held positive views the interviewed women had migrated from countries overall on growing old in Denmark. However, remi- where there are markedly different expectations as to gration seemed to be a subject of ongoing discussion the social roles for elderly people as well as different so- among these women, with some expressing ‘a dream’ of cial norms regarding provision of care for the elderly. returning to their countries of birth during old age, These expectations were acknowledged as difficult to thereby supporting the findings made by Anwar [8]. meet in the Danish context, and most women thus Since only a few of the interviewees had reached old age, seemed to accept new forms of care, such as homes for it is important to acknowledge that perceptions of where the elderly, to supplement or replace care provided by to live during the final part of one’s life were, for most relatives. Although cultural values may suggest that eld- women, still imaginary rather than actual dilemmas that erly migrants have high expectations for family support needed to be confronted. The rather open and positive and will be reluctant to use formal sources of elderly attitude to homes for the elderly may partially be care, several qualitative studies among older migrants in explained by this age effect. Importantly, perceptions of Britain suggest that elderly migrants acknowledge the where to spent one’s old age were shaped by migrant difficulty of upholding the ideal of family support whilst status, with refugees facing constraints that made it diffi- also accepting and expecting high standards of social cult to even envision aging in their countries of birth. services [6, 7]. Nevertheless, some women voiced con- Access to healthcare services is related to both primary cerns about Danish social services, in particular in terms and secondary care. Due to increasing morbidity, the of risks of isolation and language barriers. This finding is interviewees had frequent health assessments and refer- supported by a study by Mian [26], who identified very rals to specialist care made by their GPs. They expressed few Pakistani elderly women at homes for the elderly in trust and satisfaction with their GPs, which may seem Denmark, mainly caused by perceived risk of language surprising in context of the language barriers experi- barriers, fear of losing contact with their children, and a enced by most of the women, which may impede access perception of homes for the elderly as an unfamiliar con- to and quality of healthcare delivery [23]. These positive cept. The establishment of separate sections within homes perceptions perhaps point to the importance of the pri- for the elderly dedicated to migrants, who may share ex- mary healthcare structure in Denmark in which every periences of migrating from one country to another, could citizen is listed with a community-based GP, who serves create a safe environment, yet results from the present as an entry point to diagnostics, treatment, and specia- study indicate the problems with establishing such homes, lised care for many age-related health conditions. As a particularly in terms of the lack of a shared cultural and result, many patients form long-term relationships with linguistic background across diverse migrant groups. their GPs, thus partly explaining the high levels of trust Interestingly, other social services for the elderly, such as and satisfaction that women voice in discussions about home care, were not mentioned as alternatives to family- their utilisation of primary care. based care. This could be due to limited awareness of In terms of the quality of secondary, hospital-based these forms of care since studies among older migrants in care, women expressed more mixed perceptions but still Britain indicate that these migrants lack knowledge of so- preferred Danish healthcare services, which were per- cial services available to the elderly [6, 7]. ceived to be based on need rather than ability to pay, in Social relationships with children, grandchildren, hus- contrast the situation in most of the women’s countries bands, and other migrant women living in Denmark also of birth. In Denmark, most patient satisfaction surveys influenced the women’s quality of life with respect to are conducted in Danish and do not include large num- aging and return migration. All of the women had trans- bers of ethnic minorities. A number of studies among national ties to relatives in their countries of birth [21, 27], migrants in Europe point to negative perceptions of but those women who came to Denmark for family reuni- accessibility and quality of healthcare due to language fication a long time ago had spent many years in Denmark barriers, differences in expectations, and perceived and had often established family and extended social net- discrimination, combined with reluctance to assert works in the country. These women did not articulate Kristiansen et al. BMC Health Services Research (2015) 15:225 Page 10 of 12

plans of returning to their countries of birth. For the healthcare and social services, relationships to their closest women who arrived to Denmark later on as refugees, ad- family, and feelings of belonging in Denmark nourished a ditional factors seemed to influence their experiences with wish to stay rather than remigrate. Nevertheless, our data aging in Denmark, and there seemed to be a tendency for underscores that decision-making processes are complex these women to miss their country of birth more. It is and shaped by a number of situational factors, in particular worth noting that the Danish state offers financial support for refugee women, who are prevented from remigration for refugees who choose to leave the country – a benefit by legislation, security concerns, and/or responsibilities for that could influence decisions on returning to their coun- sending remittances to relatives in their countries of birth. tries of birth. However, the women in the present study As we recruited interviewees through diverse communities stressed the importance for their quality of life of well- for migrants and were able to conduct interviews within functioning healthcare and social services in Denmark existing social relationships, women seemed to be more and the ability to stay with their children and husbands. A easily recruited and more comfortable sharing experiences Danish study has likewise shown the importance of social and perceptions related to aging. We were able to recruit relationships with children and grandchildren among women with little formal education who also faced lan- elderly Turkish and Pakistani immigrants in Denmark, guage barriers, socioeconomic vulnerabilities, and suffered suggesting that remigration depended upon whether from one or more illnesses. These women are often under- younger generations were willing and able to leave represented in migrant studies, and in several instances, Denmark [10]. The former study and our data, however, they voiced appreciation of having the opportunity to dis- indicate that the children and grandchildren of middle- cuss their perceptions and needs for support in achieving aged and elderly migrants seem to settle down in as good a quality of life as possible during old age. As such, Denmark and do not wish to return to a country in which findings are likely to tap into perceptions among low- they will lack social networks, experience fewer job oppor- literacy migrant women. Nevertheless, women included in tunities, and have access to substandard education our study were not the most isolated since they engaged systems compared to the Danish system. War and poverty with other migrants and seemed comfortable critically dis- in their countries of birth additionally made it difficult for cussing their perceptions of living as migrant women in the women to return, and the women expressed concerns Denmark and the associated dilemmas related to aging. about having become estranged from the country since it More isolated women would likely face additional chal- may have changed dramatically while they were away. The lenges in coming to terms with aging-related dilemmas women seemed to long for their countries of birth as they and choices. The high prevalence of chronic illness among were before they fled. The women thus had conflicting our sample has important implications for findings and desires: They longed for their countries of birth but at the may in particular explain the importance given to accessi- same time did not wish to return. After having lived in bility and quality of healthcare services in Denmark. In Denmark for many years, the women in the present study addition, the emphasis placed on healthcare services dur- had become accustomed to new ways of life, and they ing interviews may be shaped by the fact that women were worried that, if they returned to their countries of birth, it recruited for a study on mammography screening, thus would be difficult for them to adjust to life in countries likely setting an agenda focused on disease and healthcare they had left many years earlier. At the same time, many access. We tried to counter this by emphasising broader of the women were the primary provider for relatives in aspects related to aging, including well-being, social their countries of birth through remittances and, as such, networks and quality of life. Although aging is of course were dependent on their state pension in Denmark. associated with risks for declining functional ability and Decision-making with regard to preferred place of aging rising morbidity, for healthier middle-aged women, choices therefore emerged as a complex process involving the of returning to their countries of birth are likely less balancing of the various personal and social circumstances dependent upon accessibility and availability of healthcare influencing these middle-aged migrant women. services. Since this study is cross-sectional, we are unable Within the health sciences literature, the so-called ‘myth to explore how perceptions change over time and how of return’ is maintained, suggesting that there is little need factors such as illness, death of a spouse, or intergenera- for adaptation of healthcare and social services to accom- tional dynamics may shape perceptions of remigration modate the needs of elderly migrants as these groups are during old age. From our data, questions of returning to likely to remigrate after retirement [4, 8]. However, the their countries of birth seemed to be a topic frequently de- present results concur with previous studies indicating bated within social networks, and decision-making devel- that even though migrants might dream of returning to oped over time. Longitudinal qualitative studies are needed their countries of birth, they seem to prefer staying in the to explore the dynamics of this process and how it is country of immigration in practice [8, 9]. Among the shaped in response to, for instance, contextual factors in middle-aged women in the present study, accessible Denmark and countries of birth. Last but not least, Kristiansen et al. BMC Health Services Research (2015) 15:225 Page 11 of 12

qualitative studies among migrant men are warranted to analysis does not allow for a more elaborate, theory- further our understanding of the experiences of aging driven analysis exploring each theme in greater detail. among these population groups. More in-depth qualitative studies, preferably employing a The results pave the way for discussion of how to think longitudinal design following women as they age, will be about ‘home’ in a globalised world. In a time of globalisa- necessary to ensure a better understanding of the com- tion, ‘home’ is no longer a fixed place but has increasingly plexities of aging in a European migration context. A lon- turned into something fluid; a set of practices, memories, gitudinal design would furthermore enable identification and myths [9]. Therefore, as Gardner [9] argues, there is of the extent of future remigration among these middle- no “easy return” for migrants. The maintenance of trans- aged women. national ties along with a desirable life in Denmark resulted Womenwhoareinapositivefinancialsituationand in the women often expressing feelings of belonging to who originally migrated from more affluent countries with more than one geographical location. As argued by many well-developed systems probably face fewer dif- migration scholars, migration cannot be understood as a ficulties travelling as well as paying for and using health- one-way movement that results in the gradual integration care services in their countries of birth compared with the of migrants into the receiving country [21, 27]. While mi- women included in our study. Perceptions of aging and gration by definition means a change in geographical loca- quality of life may also differ between genders, and there is tion, migrants retain ties to their countries of birth as well a need for more studies among migrant men. In addition, as to relatives settling down in other countries. Integration studies are needed to identify specific needs in encounters into a country and enduring transnational ties are there- between middle-aged and elderly migrants within the con- fore neither incompatible nor binary opposites [27]. text of current healthcare and social services. Migrants might feel that they belong to a variety of geo- graphical locations simultaneously. In our study, the Conclusions women voiced feelings of belonging to both Denmark and Migrants’ perceptions of aging, including whether to remi- their countries of birth, in many ways becoming citizens grate or stay in the immigration country, are shaped by of the world through their global pathways and networks multiple factors, including access to quality healthcare and [21]. The women were satisfied with the quality of life in social services, social relationships, and feelings of belong- Denmark and wished to stay in the country. Healthcare ing. The women represented in the present study empha- and social services should therefore embrace the needs of sised the importance of access to the Danish healthcare the growing number of elderly migrants, some of whom, system and held positive views on social care available to particularly refugee women, may experience language bar- the elderly in Denmark. Social relationships in Denmark, riers, fragile social networks, and significant responsibil- most importantly intergenerational ties, further nourished ities and emotional ties to their countries of birth, which their desire to stay in the country although some women, must be taken into account in service-delivery [4, 6, 7, 28]. especially those who came as refugees, dreamed of return- Some needs might be met by securing access to transla- ing to their countries of birth during old age. Fear of hav- tors as well as conducting a systematic assessment of ing been estranged from values and practices in their social relations followed by a referral to, e.g., volun- countries of birth as well as financial and safety issues kept teers and organisations for elderly people. In addition, them from doing so. Our findings suggest that elderly mi- separate sections dedicated to migrants at homes for grants from diverse cultural and linguistic backgrounds the elderly could be considered in order to create a will choose not to remigrate and will instead utilise health- culturally and linguistically familiar environment for care and social services in Denmark. This necessitates the elderly, although these could be difficult to imple- continued focus on ensuring that needs among Europe’s mentduetothediversityamongthesegroupsand increasing elderly migrant population are adequately met. could lead to segregation from other ethnic groups. Abbreviation Limitations of the study GP: General practitioner.

Due to the relatively limited data sample covering diverse Competing interests groups of migrants, the present study is explorative and The authors declare that they have no competing interests. particularly points to the need for longitudinal qualitative studies among larger groups of migrant women in order Authors’ contributions LLK and MK designed the study and carried out the interviews and analysis. to understand the needs of populations with diverse ethnic MK and LLK drafted the manuscript. MN and AK participated in the design of and social backgrounds. As the present analysis builds the study and helped draft the manuscript. All authors read and approved upon data collected as part of a broader study on health the final manuscript. The Psychosocial Research Committee, Danish Cancer Society, funded the study. The research team is independent of the funders, behaviour among migrant women, the depth of data col- and the views expressed are those of the researchers, not the funding body. lected in relation to each of the themes covered in the This study adheres to the RATS guidelines on qualitative research. Kristiansen et al. BMC Health Services Research (2015) 15:225 Page 12 of 12

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